The October 2024 Foot & Ankle Roundup³⁶⁰ looks at: Hemiarthroplasty for hallux rigidus; Fixed or mobile-bearing ankle arthroplasty? A meta-analysis; Bone grafting for periprosthetic bone cysts following total ankle arthroplasty; Diabetic foot ulcer after first-ray amputation; Early motion after ankle surgery: the path to faster recovery?; Are podiatrists and orthopaedic surgeons approaching zone 2 fifth metatarsal fractures in the same way?.

Aims. This study aimed to compare the outcomes of two different postoperative management approaches following surgical fixation of ankle fractures: traditional cast immobilization versus the Early Motion and Directed Exercise (EMADE) programme. Methods. A total of 157 patients aged 18 years or older who underwent successful open reduction and internal fixation (ORIF) of Weber B (AO44B) ankle fractures were recruited to this randomized controlled trial. At two weeks post-surgical fixation, participants were randomized to either light-weight cast-immobilization or the EMADE programme, consisting of progressive home exercises and weekly advice and education. Both groups were restricted to non-weightbearing until six weeks post-surgery. The primary outcome was assessed using the Olerud-Molander Ankle Score (OMAS) questionnaire at 12 weeks post-surgery, with secondary measures at two, six, 24, and 52 weeks. Exploratory cost-effectiveness analyses were also performed. Results. Overall, 130 participants returned their 12-week OMAS questionnaires. The mean OMAS was significantly higher in the EMADE group compared with the immobilized group (62.0 (SD 20.9) vs 48.8 (SD 22.5)), with a clinically meaningful mean difference of 13.2 (95% CI 5.66 to 20.73; p < 0.001). These differences were maintained at week 24, with convergence by week 52. No intervention-related adverse events, including instability, were reported. Conclusion. The EMADE programme demonstrated an accelerated recovery compared to traditional six-week cast immobilization for those who have undergone ORIF surgery to stabilize Weber B (AO44B) ankle fractures. The study found the EMADE intervention to be safe. Cite this article: Bone Joint J 2024;106-B(9):949–956

Background. Ankle fractures are extremely common but unfortunately, over 20% fail to obtain good to excellent recovery. For those requiring surgical fixation, usual-care post-surgery has included six-weeks cast immobilisation and non-weightbearing. Disuse atrophy and joint stiffness are detrimental sequelae of this management. While rehabilitation, starting at two-weeks post-surgery is viewed as safe, the literature contains methodological flaws and a lack of focus on early exercise, perpetuating the controversy over the effectiveness of early exercise interventions. Objectives. Our objectives were to determine if following operative fixation for Weber B fracture, the physiotherapy intervention, early motion and directed exercise (EMADE), applied in the clinical setting, were superior to Usual-care at 12-weeks (primary outcome) and 24-weeks. Design and Methods. We undertook a pragmatic-RCT, recruiting 157 surgically fixed Weber B ankle fracture patients, to establish if EMADE was superior to the Usual-care of 6-weeks immobilisation. The EMADE physiotherapy intervention (between week-2 and 4 post-surgery) utilised a removable cast and combined non-weightbearing progressive home exercises with manual therapy, advice and education. The primary outcome measure was the OMAS at 12-weeks. Results. 130 participants returned their 12-weeks post-surgery data, exceeding the 60/group threshold set by the a-priory power calculation. Group OMAS means were; 62.0 and 48.8 (SD 21, 22.5) EMADE, Usual-care respectively, yielding a clinically meaningful mean difference of 13.2 on the OMAS and a statistical difference (95% CI p< 0.001, 5.66 to 20.73). Both clinically meaningful and statistically significant findings were maintained at week-24. There were no intervention related or unexpected adverse events, including instability. Conclusions. This clinic set pragmatic-RCT yielded both clinical and statistical outcomes at week-12 in favour of the EMADE physiotherapy intervention over the Usual-care of 6-weeks immobilisation, in surgically fixed Weber B ankle fracture patients. These positive findings were maintained at week-24 and justify EMADE physiotherapy as a viable treatment option

Myriad protocols exist for isolated Weber B lateral malleolus fractures with a congruent tibiotalar joint on initial radiographs. Stress and weight-bearing radiographs, all at various timepoints, may be employed to identify those injuries that develop significant talar shift but consensus is elusive. This study outlines a safe and reproducible protocol for such injuries, utilising a removable orthosis, immediate weight bearing and standard supine radiographs. A retrospective analysis of a prospective trauma database was analysed to identify patients with an isolated Weber B ankle fracture with adequate presentation radiographs demonstrating a congruent mortise. Patient records and radiographs were evaluated a minimum of 5 years after initial presentation to determine ankle stability, complications, and the burden on outpatient services. Between 2014 and 2016, 657 patients were referred to the specialist trauma clinic from the emergency department. Of the 657, 52 patients had inadequate ED radiographs to determine ankle congruity. At the two-week assessment, 11 of the 52 demonstrated talar shift and required intervention. Therefore 646 patients demonstrated ankle congruity at two weeks after weight bearing. No patient demonstrated talar shift at the six-week assessment. Average number of follow up appointments was 2.4 with 3.5 radiographs. Our new treatment protocol advocates discharge after a single orthopaedic assessment after two weeks of weight bearing. This study supports immediate weight-bearing of Weber B ankle fractures with a congruent mortise in an orthosis. Follow up beyond two weeks is unnecessary and our protocol offers a safe means of significantly reducing the outpatient burden

Aims. Treatment of Weber B ankle fractures that are stable on weightbearing radiographs but unstable on concomitant stress tests (classified SER4a) is controversial. Recent studies indicate that these fractures should be treated nonoperatively, but no studies have compared alternative nonoperative options. This study aims to evaluate patient-reported outcomes and the safety of fracture treatment using functional orthosis versus cast immobilization. Methods. A total of 110 patients with Weber B/SER4a ankle fractures will be randomized (1:1 ratio) to receive six weeks of functional orthosis treatment or cast immobilization with a two-year follow-up. The primary outcome is patient-reported ankle function and symptoms measured by the Manchester-Oxford Foot and Ankle Questionnaire (MOxFQ); secondary outcomes include Olerud-Molander Ankle Score, radiological evaluation of ankle congruence in weightbearing and gravity stress tests, and rates of treatment-related adverse events. The Regional Committee for Medical and Health Research (approval number 277693) has granted ethical approval, and the study is funded by South-Eastern Norway Regional Health Authority (grant number 2023014). Discussion. Randomized controlled trials are needed to evaluate alternative nonoperative treatment options for Weber B/SER4a ankle fractures, as current clinical guidelines are based on biomechanical reasoning. The findings will be shared through publication in peer-reviewed journals and presentations at conferences. Cite this article: Bone Jt Open 2023;4(9):713–719

Aims

Ankle fracture fixation is commonly performed by junior trainees. Simulation training using cadavers may shorten the learning curve and result in a technically superior surgical performance.

Background

Due to the overwhelming demand for trauma services, resulting from increasing emergency department attendances over the past decade, virtual fracture clinics (VFCs) have become the fashion to keep up with the demand and help comply with the BOA Standards for Trauma and Orthopaedics (BOAST) guidelines. In this article, we perform a systematic review asking, “How useful are VFCs?”, and what injuries and conditions can be treated safely and effectively, to help decrease patient face to face consultations. Our primary outcomes were patient satisfaction, clinical efficiency and cost analysis, and clinical outcomes.

Introduction. The conservative management of stable Weber B fibula fractures remains variable. We thought that the current trend in our institution poses an unnecessary burden on fracture clinics. Methods. We reviewed patients referred with Weber B ankle fractures over an 18 month period. Our inclusion criteria were non-diabetic adults, with isolated stable Weber B fractures. Fractures were deemed stable if they had no evidence of talar shift on initial radiographs (< 5mm medial clear space and < 1mm variation between superior and medial clear spaces). Exclusion criteria were unstable fractures on radiographs, or no local follow-up. Management was reviewed from case notes and radiographs. Primary outcome was the stability of the fracture by the end of treatment. Secondary measures were duration of treatment, number of follow up appointments and radiographs, and complications. Results. 182 cases were reviewed. 82 were excluded leaving 100 patients for follow-up. Mean age was 53 (18–99). Mean number of outpatient appointments was 2.63 (1–6), follow up radiographs was 2.34 (0–6). 74 were treated in a walking boot and 15 in a walking cast for a mean of 6 weeks (4–9) and allowed to full weight-bear. 10 were kept non weight-bearing in a cast for 6 weeks and 1 was partially weight-bearing. Mean follow-up time was 7.3 weeks (1–30). No fractures displaced and one patient developed an ulcer from a cast. Conclusion. Our study suggests that in isolated Weber B fractures, with no radiographic instability on initial presentation, further displacement is unlikely. We propose that these injuries can be treated safely in a removable boot with full weight-bearing for 6 weeks then clinical and radiologic assessment if required. Casting or restricted weight-bearing does not confer any additional advantage. We question the necessity and rationale behind weekly clinical and radiological follow-up for such cases

Background. The Fracture Fixation Assessment Tool score (FFATs) was developed as an objective evaluation of post-operative fracture fixation radiographs as a means of appraisal and education. The tool has proven validity, simple to use and based upon AO principles of fracture fixation. This study has been designed to assess how FFATs changes throughout the training program in the UK. Methods. The local trauma database of a district general hospital, with trauma unit status was used to identify cases. Although FFATs is designed to apply to any fracture fixation, Weber B ankle fractures were selected as common injuries, which constitute indicative cases in T&O training. Grade of the primary surgeon and supervision level were both stratified. The initial and intraoperative radiographs were anonymised and presented to the assessor who had been blinded to the identity and grade of the surgeon, for scoring using FFATs. Results. 293 fractures around the ankle were identified from the Database between 2013 and 2016. After applying the inclusion criteria of Weber B fractures operatively fixed, Specialist training registrars and consultants, there were 99 cases for evaluation. These were grouped by training experience into 4 groups. (ST3-4, ST5-6, ST7-8, Consultants) and demonstrated a trend of increasing scores with experience level with a dip in consultant scores, albeit not statistically significant due to low numbers of cases at higher training grades. Conclusions. We present our first experience of using FFATs in a uniform series of fractures in surgeons of different training grades. There is a trend to increasing scores throughout training with a dip in consultant scores likely reflecting increased complexity of cases. Implications. FFATs could prove to be an invaluable appraisal tool for teaching and mentoring surgeons in training both locally in the United Kingdom and remotely overseas

The June 2015 Foot & Ankle Roundup³⁶⁰ looks at: Syndesmosis and outcomes in ankle fracture; Ankle arthrodesis or arthroplasty: a complications-based analysis; Crosslinked polyethylene and ankle arthroplasty; Reducing screw removal in calcaneal osteotomies; Revisiting infection control policies; Chevron osteotomy: proximal or distal?; Ankle distraction for osteoarthritis

Introduction:. Unstable ankle fractures are commonly treated with operative fixation. Isolated lateral malleolus fractures (Weber B) are often operated by orthopaedic trainees. Operative fixation of these fractures is included in the index procedures of procedure based assessment (PBA) of intercollegiate Surgical Curriculum Programme (ISCP). Orthopaedic trainees are expected to be competent in this procedure by the end of their training. Fluoroscopic guidance is essential for adequate reduction and safe fixation of these fractures. Aims:. It is currently unknown if patients are exposed to excess radiation when they are operated by trainees compared to consultant surgeons. It is a common perception that trainees take more time to fix these fractures compared to trained consultants thereby exposing patients to untoward effects of prolonged tourniquet time. Method:. A retrospective review of fifty patients undergoing operative fixation of Weber B lateral malleolus fractures were undertaken. Twenty five patients were operated by orthopaedic consultants and the remaining (n=25) by orthopaedic trainees. The tourniquet time and the intra-operative radiation dose using the fluoroscope were recorded. Results:. Patients operated by trainees were exposed to significantly higher dose of intra-operative radiation (median, 6.5 Gy vs 46.2 Gy; interquartile range, 0.87–15.8 vs 8.37–140.3; P=0.003). However, there was no statistical difference in the duration of application of the tourniquet in between the two groups (median, 59 minutes vs 79 minutes; interquartile range, 45–95 vs 69–102; P=0.12). Discussion:. This is the first study to indicate that patients are at risk of higher radiation exposure when operated by orthopaedic trainees whilst the times taken to fix Weber B ankle fractures are almost similar to those undergoing surgery by a consultant grade surgeon

The December 2013 Foot & Ankle Roundup. 360 . looks at: Maisonneuve fractures in the long term; Not all gastrocnemius lengthening equal; Those pesky os fibulare; First tarsometatarsal arthrosis; Juvenile osteochondral lesions; Calcanei and infections; Clinical outcomes of Weber B ankle fractures; and rheumatologists have no impact on ankle rheumatoid arthritis.

We assessed the rates of fracture healing in a number of patients in Southern Africa where the Human Immunodeficiency Virus (HIV) is highly prevalent. Our aim was to deduce whether rates of union were affected by HIV and its subsequent clinical stages, including the Acquired Immune Deficiency Syndrome (AIDS). We evaluated 2376 patients with Weber B ankle fractures without talar shift. All the patients included in the study were tested for HIV using the Western Blot system and classified according to the WHO classification (Stages I–IV). From the sample group, 829 patients were HIV negative. 729 were HIV positive belonging to Stages I–III, whilst 755 were HIV positive in stage IV of the disease. Patients were all treated conservatively in below knee casts for a minimum of six weeks. All the patients were aged between 20 and 30. All patients were all part of similar socioeconomic circumstances and were non-smokers who used no dietary supplements. From the sample of patients we reviewed, the results were as follows. In the HIV negative category, 56% of patients had fracture union at 4 weeks, 32% had fracture union at 6 weeks, 10.5% had fracture union at eight weeks and 1.5% of patients suffered non-union of the fractures. In the HIV positive group (WHO Stages I–III), 54.7% of patients had fracture union at 4 weeks, 33.7% had fracture union at 6 weeks, 10.2% had fracture union at 8 weeks and 1.26% of patients suffered non-union. From the HIV positive category (WHO Stage IV), 18.28% of patients had fracture union at four weeks, 32.72% had fracture union at 6 weeks, 36.56% had fracture union at 8 weeks and 12.45% of patients suffered non-union of the fractures. Healing and union were described as sufficient callous formation, no further displacement, and no malleolar tenderness at the time of cast removal. In addition to this, the patients must have been able to fully weight bear. There was no significant statistical difference in fracture union between patients who were HIV negative and the patients with HIV stages one to three. There were significant differences between the above mentioned groups and patients with Stage IV HIV/AIDS. In essence, the more progressive the disease, the higher the rates of non-union

Background: Ankle fractures in adults are an increasing part of the workload of orthopaedic surgeons today. Stable ankle fractures are usually managed conservatively and followed up in the fracture clinic to identify any later displacement which may lead to the need for surgical treatment. the guidelines for follow up varies from place to place with equally varying outcomes. the aim of this study was to look at the pattern and outcome of follow up of these fractures and also the influence, if any, of serial radiological imaging during this period. Methods: We retrospectively reviewed the follow up of patients who were refered to the clinic as stable ankle fractures and who were treated conservatively following their first clinic attendance. the period covered was April 2002 to march 2003 and we also assessed the documentation of medial side tenderness from the casenotes. Results: 66 patients were identified consisting of 44 Weber A, 20 Weber B and 2 Weber C fractures with an average follow up of 10weeks. 82% of cases had documented medial side tenderness. None of the Weber A fractures displaced, irrespective of weight bearing instructions and medial side tenderness. Only 2(10%) of the Weber B and 1 (50%) of the Weber C fractures required surgical intervention due to displacement detected after clinic review at week one. Conclusion: Weber A fractures are inherently stable injuries, do not displace over time and hence do not require further clinic attendances and xrays after the first consultation. Beyond the first week, regular clinic reviews and serial xrays are not necessary in the treatment of Weber B ankle fractures. The presence of medial side tenderness was a poor indicator for joint instability in this series. with proper protocols in place, these can lead to a significant decrease in the workload of orthopaedics surgeons

To reduce both operative trauma and wound length in plate osteosynthesis of dislocated WEBER type B fractures of the distal fibula we started using 3 hole one-third tubular „anti-glide“ AO plates in 1996 instead of longer implants. From 1996 to 2001 a total of 72 patients with isolated WEBER type B fractures were treated operatively by using 3 hole one-third „anti-glide“ AO plates. A clinical and radiographic follow-up examination was performed after 38.6 [18–63] months using the original WEBER score. The statistical method to compare our results with previous investigations was Chi-Square-Test according to Pearson (p=0.05). 67 (93.1%) of all patients were without complaints while 3 (4.2%) complained about exercise induced pain and 2 (2.7) reported rest pain. 69 (95.8%) patients showed identical ranges of ankle joint movement, whereas 3 (4.2%) patients had minimal loss of joint function. Radiographically perfect joint configurations were seen in 69 patients while 3 (4.2%)showed grade 1 arthrosis according to BARGON. A total of 68 (94.4%) patients showed very good (n=50) or good (n=18) results according to Weber. In 4 cases the result was not satisfying. This was not significantly different from other investigations with longer implants, but scar length was reduced and duration of after-treatment was signifcantly faster than treatment with longer implants (p< 0.05). It is concluded that operative stabilisation of isolated Weber type B ankle fractures with 3 hole dorsal „anti-glide“ AO plates can be recommended as a safe, convenient, cost-effective and simple alternative to the use of longer implants